Ucl Injury To The Elbow Essay, Research Paper
Ulnar Collateral Ligament Injury to The Elbow:
Focusing on Throwing Athletes
Jose M. Barillas
Assessment of Athletic Injuries
Ulnar collateral ligament, Tommy John s procedure (surgery), medial collateral ligament, and pitcher s elbow, are all the same injury relating to the ligament in the elbow. This ligament is commonly injured in throwing athletes because of excessive forces generated across the elbow during throwing. This is the reason why I am focusing my paper on throwing athletes because it is very common to baseball players. The ulnar collateral ligament is located on the inside of the elbow on the medial side of the elbow. It is a fan shaped structure and it is similar to the knees medial collateral ligament (Magee, 2000). The ligament is a band or sheet of fibrous tissue that connects the distal aspect of the humerus to the proximal aspect of the ulna and supports the arm muscles while pitching.
This injury is very common in baseball athletes; it has put many MLB players on the sidelines. For example, John Smoltz, Nolan Ryan, Jose Canseco, Tommy John, and many other more. Why did it get the name Tommy John procedure? It got its name Tommy John procedure because back in 1974 he was diagnosed with a career threatening torn ulnar collateral ligament. He told the doctor (Frank Jobe) to do what ever he has to do so he can get back out in the fields and so Dr. Jobe did a surgery that let Tommy John play for 12 more years. I would discuss the procedure Dr. Jobe did later in this paper.
Mechanism and History
The mechanism of the ulnar collateral ligament is of excessive force used in the elbow. The wide variety of breaking pitches used today, such as the sharp curve ball, cutter, and split finger fastball, can cause strain on the elbow. With throwing and particularly pitching, there are strong forces pulling the inside of the elbow in different
directions. At the same time, there are compressive forces on the outside of the elbow. The symptoms are primarily pain on the inside of the elbow. This usually occurs as the individual increases the velocity of throwing over time. Frequently, the pain will go away with rest, and then it will come back again when the velocity is increased.
The history is usually positive for pain on the medial side of the elbow with throwing especially during the late cocking and early acceleration phases (Prentice, 2000). This is why many athletes that involve throwing have had some sort of injury to their elbow. There have been many injuries to this ligament to professional baseball athletes. For example in pitchers, improper mechanics, particularly opening up to soon increases the tension across the arm at the elbow. Poor mechanics, lack of flexibility, and over all conditioning, as well as fatigues from overuse can all have an overall effect that leads to a decrease in active muscular protection of the medial elbow and producing greater stress to the ulnar collateral ligament (Ellenbecker/ Mattalino p. 29).
Purpose of the Procedure
When greater stress to the ulnar collateral ligament becomes very painful and you can t throw or do anything, then that is when you have to go through the surgical procedure. The purpose of the procedure is to stop pain and to return to a complete range of motion. Many MLB pitchers go through the surgery so they can get back out to the fields. That is the reason Tommy had the surgery. Jobe performed the procedure of the surgery Tommy had. Jobe extracted a tendon from John s right arm and used it to
replace the torn ligament on his left, pitching arm, threading the healthy tendon through holes drilled into the bone above and below the elbow.
Ulnar Collateral Ligament Test
The condition of the ulnar collateral ligament of the elbow can be tested using a valgus stress test. The test should be administered with the elbow in approximately 25 degrees of flexion. Testing in 25 degrees of flexion removes the olecranon from the olecranon fossa and decreases the bony congruity of the elbow joint, thereby placing greater stress on the ulnar collateral ligament (Ellenbecker p. 55). The extremity being tested should be held such that humeral external rotation is blocked. A valgus stress is exerted while palpating the ulnar collateral ligament region on the medial aspect of the elbow. Excessive gaping of the injured extremity, compared bilaterally, indicates weakness of the ulnar collateral ligament. The amount of opening as well as the perceived end feel should be tested and compared bilaterally. Pain may be present with the valgus stress applied to the elbow. Isolation of motion to valgus stress without humeral rotation or elbow extension/flexion at the elbow should be targeted (Ellenbecker p. 55)
Initial Postoperative Findings
Minimal swelling is noted in the medial forearm and posterior aspects of the elbow. Grip strength is 50 kg on the left extremity and 10 kg on the right (Ellenbecker p. 152). The patient is fully intact to light touch sensation, except for the region immediately surrounding the medial open incision. When these findings are present then surgery is to take place.
Description of the Surgery
The most common tendon used for replacement is the palmaris longus. It is in the
front of the wrist, and it is a tendon that does not have any specific function, so it serves perfectly as a grafting tissue. Conway and Jobe describe the surgical technique to reconstruct the UCL very extensively:
A 10 cm medial incision is made over the medial epicondyle to provide exposure, with
careful dissection and protection of the ulnar nerve carried out before the ulnar collateral
ligament is addressed. If a primary repair is performed, adequate normal appearing ligam-
entous tissue is present, a reconstruction is performed. Additional exposure is required to
perform the reconstruction, which is obtained by transection of the flexor/pronator tendi-
nous origin. This has important ramifications with respect to rehabilitation. Removal of
this tendinous origin results in more time being required for healing and a lengthier peri-
od before resistive exercise of the flexor/pronator muscles and forearm supination and
wrist extension range of motion can be performed.
Calcification within the ligament and surrounding soft tissues is also removed, with relo-
cation of the ulnar nerve performed by removing it from the cubital tunnel. The ulnar
nerve is mobilized from the level of the arcade of struthers to the interval between the
two heads of the flexor carpi ulnaris. The attachment sites of the anterior band of the
ulnar collateral ligament are identified, and tunnels are drilled in the medial epicondyle
and proximal ulna to approximate the anatomical location of the original ligament. The
graft taken from the ipsilateral palmaris longus (if available) is then placed in a figure of
eight fashion through tunnels. The ulnar nerve is carefully transposed so that no impinge-
ment or tethering occurs. The flexor/pronator origin is then reattached. The elbow is
immobilized in a position of 90 degrees of flexion and neutral rotation, with the wrist left
free to move. (p. 135)
This is part of the operation that Frank Jobe did to Tommy John back in 1974. Postoperative Rehabilitation
Treatment begins with initial rest and ice. After approximately 36 hours, heat may
be applied and NSAID s (non-steroidal anti inflammatory medication) administered (Jobe 1986). Rehabilitation frequently includes heat/ice contrast, ultrasound, and electronic stimulation. Stretching and strengthening of the flexors and extensors is indicated once discomfort has gone away slightly. The Tommy John surgery requires a period of immobilization, followed by a gradual rehab program including range of motion exercises, followed by strengthening exercises, then a return to functional activities.
It is usually an effective operation. It is a high percentage recovery surgery. Many pitchers come back and pitch for at least 6 years or more. It takes less time in the operating room and players can start rehabilitation right away. Many players come back with a few more miles per hour on their fastball. Transplanted tendons have three times the amount of collagen, than the original tendon (Dawkins 2000).
Not all surgeries are success stories. There is only a 70 percent to 80 percent success rate. It takes time for post surgical recovery. It takes anywhere from six months to two years. The main reason it takes time to recover is that the graft itself cannot survive because it has no blood supply. The primary function of the graft is to provide scaffolding for normal tissue to grow onto, so over time it will be replaced by living, normal tissue, which provides the stability of this, joint. You cannot speed up the process (Pedegana). There is also a high incidence if complications related to the ulnar nerve.
Ulnar collateral ligament injuries frequently occur in pitchers because of faulty mechanics. By learning proper throwing mechanics early in a baseball career and developing leg, back, torso, and shoulder strength, many UCL problems can be avoided.
Arnheim, D. D., & Prentice, E. (2000) Principles of Athletic Training. (10th Edition) U.S.: McGraw-Hill Companies.
Azar FM, & Andrews JR, (2000). Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. The American Journal of Sports Medicine. Vol. 28 (1) 16-23.
Ellenbecker, T.S., & Mattalino, A.J. (1997)The Elbow in Sport. U.S.: Braun-Brumfield.
Hechtman KS, (1998). Biomechanics of a less invasive procedure for reconstruction of the ulnar collateral ligament of the elbow. The American Journal of Sports Medicine. Vol. 26 (5), 620-624.
Jobe, F. & Stark, H. (1986) Reconstruction of the ulnar collateral ligament in athletes. Journal of Bone and Joint Surgery. Vol. 68, (8) 63.
Kindred, D. (2000) The passion to throw again. Sporting News. Vol. 224 (31) 62.
Magee, D. J. (1997) Orthopedic Physical Assessment. (3rd Edition) U.S.: W.B. Saunders Company.